Apparatus and methods for delivery of transcatheter prosthetic valves

ABSTRACT

In some embodiments, an apparatus includes a catheter assembly and a handle assembly that can be removably coupled to the catheter assembly. A valve holding tube defines a lumen configured to receive a prosthetic mitral valve in a compressed configuration and can be removably coupled to a distal end portion of the handle assembly. The valve holding tube can be received within a hub of the catheter assembly when coupled to the handle assembly. The actuator when actuated is configured to cause the tensioning unit to travel along a traveler strap of the catheter assembly moving the handle assembly distally such that a distal end of an elongate shaft of the handle assembly moves the prosthetic mitral valve distally out of the valve holding tube and out a distal end of the sheath such that the prosthetic mitral valve is free to move to a biased expanded configuration.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation of U.S. patent application Ser. No. 15/388,571, filed Dec. 22, 2016, which is a continuation of U.S. Pat. No. 9,526,611, filed Oct. 29, 2014, which claims priority to and the benefit of U.S. Provisional Patent Application No. 61/896,664, filed Oct. 29, 2013, entitled “Improved Delivery Systems for Transcatheter Prosthetic Valves,” each of the disclosures of which is incorporated herein by reference in its entirety.

BACKGROUND

Embodiments are described herein that relate to devices and methods for use in the delivery and deployment of transcatheter prosthetic valves, and particularly to devices and methods for delivering expandable prosthetic heart valves.

Prosthetic heart valves can pose particular challenges for delivery and deployment within a heart. Valvular heart disease, and specifically, aortic and mitral valve disease is a significant health issue in the United States (US); annually approximately 90,000 valve replacements are conducted in the US. Traditional valve replacement surgery involving the orthotopic replacement of a heart valve, is considered an “open heart” surgical procedure. Briefly, the procedure necessitates surgical opening of the thorax, the initiation of extra-corporeal circulation with a heart-lung machine, stopping and opening the heart, excision and replacement of the diseased valve, and re-starting of the heart. While valve replacement surgery typically carries a 1-4% mortality risk in otherwise healthy persons, a significantly higher morbidity is associated to the procedure largely due to the necessity for extra-corporeal circulation. Further, open heart surgery is often poorly tolerated in elderly patients. Thus elimination of the extra-corporeal component of the procedure could result in reduction in morbidities and cost of valve replacement therapies could be significantly reduced.

While replacement of the aortic valve in a transcatheter manner is the subject of intense investigation, lesser attention has been focused on the mitral valve. This is in part reflective of the greater level of complexity associated to the native mitral valve apparatus, and thus, a greater level of difficulty with regards to inserting and anchoring the replacement prosthesis. A need exists for delivery devices and methods for transcatheter mitral valve replacements.

SUMMARY

Apparatus and methods are described herein for use in the delivery of a transcatheter prosthetic mitral valve replacement. In some embodiments, an apparatus includes a catheter assembly including a sheath, a hub and a traveler strap, and a handle assembly including an actuator and an elongate shaft. The handle assembly can be removably coupled to the catheter assembly. A valve holding tube defines a lumen configured to receive a prosthetic mitral valve in a compressed configuration and is configured to be removably coupled to a distal end portion of the elongate shaft of the handle assembly. A distal end portion of the valve holding tube can be received within an interior region of the hub when the valve holding tube is coupled to the elongate shaft of the handle assembly. The actuator when actuated is configured to cause the tensioning unit to travel along the traveler strap moving the handle assembly distally such that a distal end of the elongate shaft moves the prosthetic mitral valve distally out of the valve holding tube and out a distal end of the sheath such that the prosthetic mitral valve is free to move to a biased expanded configuration.

BRIEF DESCRIPTION OF THE FIGURES

FIG. 1 is a cross-sectional illustration of portion of a heart with a prosthetic mitral valve implanted therein.

FIG. 2 is a schematic illustration of a delivery device, according to an embodiment.

FIG. 3 is a side view of a portion of a delivery device, according to an embodiment.

FIG. 4 is a perspective view of a handle assembly of the delivery device of FIG. 3.

FIG. 5 is an enlarged side view of a portion the handle assembly of FIG. 4.

FIG. 6 is an enlarged side view of a portion the handle assembly of FIG. 4 shown with a portion of traveler strap coupled thereto.

FIG. 7 is a perspective view of a catheter assembly of the delivery device of FIG. 3.

FIG. 8 is a perspective view of a valve holding tube of the delivery device of FIG. 3.

FIG. 9 is a side view of the handle assembly of FIG. 4 with the valve loading tube of FIG. 8 coupled to a distal end portion thereof.

FIG. 10 is a perspective view of a dilator device, according to an embodiment.

FIG. 11 is a side view of the catheter assembly of FIG. 7 with the dilator device of FIG. 10 coupled thereto.

FIG. 12 is a perspective view of a valve loading device, according to an embodiment.

FIG. 13 is a cross-sectional view of the valve loading device of FIG. 12 taken along line 13-13 in FIG. 12.

FIG. 14 is a side view of the valve holding tube of FIG. 8 coupled to the valve loading device of FIG. 12.

FIG. 15 is a side perspective view of a portion of the handle assembly of FIG. 4 coupled to a load assist device according to an embodiment with the load assist device in a first position.

FIG. 16 is a side perspective view of the portion of the handle assembly and load assist device of FIG. 15 with the load assist device in a second position.

FIGS. 17A and 17B are enlarged side views of a portion of a handle assembly according to another embodiment.

FIG. 18 is a flowchart of a method of delivering and deploying a prosthetic mitral valve to a heart.

FIG. 19 is a schematic illustration of a surgical kit for delivering and deploying a prosthetic mitral valve, according to an embodiment.

DETAILED DESCRIPTION

Apparatus and methods are described herein for use in the delivery and deployment of a prosthetic mitral valve into a heart. As described herein, in some embodiments, a delivery device can include a handle assembly having an actuator, a delivery catheter and a valve holding tube. The valve holding tube can be removably coupled to a distal end portion of an elongate sheath of the handle assembly and the valve holding tube and handle assembly can be collectively and movably coupled to the delivery catheter. A dilator device is also described herein that can optionally be used during a procedure to deliver a prosthetic mitral valve to the heart and can be received through a lumen of the delivery catheter and used prior to inserting the handle assembly and holding tube into the delivery catheter. The delivery device described herein can be used to deploy a prosthetic mitral valve into the heart in a controlled manner providing incremental movement of the prosthetic mitral valve within the delivery catheter and out into the heart.

In some embodiments, a method of delivering a transcatheter mitral valve replacement to the mitral annulus of a heart includes deploying into the mitral annulus a transcatheter mitral valve prosthesis using a delivery device as described herein. The transcatheter mitral valve prosthesis can be made from an expandable metal stent body having valve leaflets disposed therein. The stent body can be covered with a synthetic material or stabilized pericardial tissue and the valve leaflets can be made from stabilized pericardial tissue. The expandable metal stent body can have an optional atrial cuff and the cuff can optionally have a covering made from a synthetic material and/or stabilized pericardial tissue. The transcatheter mitral valve prosthesis can be deployed via catheter in a compressed state and expanded upon ejection from the catheter. The mitral valve prosthesis may include one or more tethers coupled to a proximal end of the prosthesis.

A distal end of the one or more tethers can be anchored in the left ventricle. The one or more tethers can be tightened by a catheter tool positioned in the left atrium that can pull the proximal end of the one or more tethers just prior to fastening the one or more tethers to establish a fixed length. Prosthetic mitral valves that can be delivered with the devices and methods disclosed herein can include those disclosed in International Patent Application Serial Nos. PCT/US14/40188 entitled “Structural Members for Prosthetic Mitral Valves,” filed May 30, 2014 (“PCT application '40188”), PCT/US14/44047 entitled “Thrombus Management and Structural Compliance Features For Prosthetic Heart Valves,” filed Jun. 25, 2014 (“PCT application '44047”), and PCT/US14/58826 entitled “Prosthetic Heart Valve and Systems and Methods for Delivering the Same,” filed Oct. 2, 2014 (“PCT application '58826”), the disclosures of which are incorporated herein by reference.

In some embodiments, a surgical kit can include a delivery device as described herein and accessory components that can be used with the delivery device in a procedure to deliver a transcatheter prosthetic valve as described herein. The delivery device and the accessory components can be disposed within a sterile package. For example, in some embodiments, a kit can include a delivery device and a dilator device and/or a valve loading device as described herein. In some embodiments, a kit can also include a transcatheter valve (e.g., a prosthetic mitral valve) and/or an epicardial pad that can be used to secure the transcatheter valve in position within the heart.

As used herein, the words “proximal” and “distal” refer to a direction closer to and away from, respectively, an operator of, for example, a medical device. Thus, for example, the end of the medical device closest to the patient's body (e.g., contacting the patient's body or disposed within the patient's body) would be the distal end of the medical device, while the end opposite the distal end and closest to, for example, the user (or hand of the user) of the medical device, would be the proximal end of the medical device.

FIG. 1 is a cross-sectional illustration of the left ventricle LV and left atrium LA of a heart having a transcatheter prosthetic mitral valve PMV deployed therein and an epicardial anchor device EAD securing the prosthetic mitral valve PMV in place. FIG. 1 illustrates the prosthetic mitral valve PMV seated into the native valve annulus NA and held there using an atrial cuff AC of the prosthetic mitral valve PMV, the radial tension from the native leaflets, and a ventricular tether T secured with attachment portions Tp to the prosthetic mitral valve PMV and to the epicardial anchor EAD. The apparatus and methods described herein can be used in conjunction with the various different types and embodiments of an epicardial anchor device, such as those described in pending International Patent Application No. PCT/2014/049218 entitled “Epicardial Anchor Devices and Methods,” (“PCT application '049218”) the disclosure of which is incorporated herein by reference in its entirety.

FIG. 2 is a schematic illustration of a delivery device, according to an embodiment. A delivery device 100 can be used to deliver and deploy a prosthetic heart valve within the heart, such as, for example, a prosthetic mitral valve. The delivery device 100 includes a catheter assembly 130, a handle assembly 120 removably coupleable to the catheter assembly 130, and a valve holding tube 125 removably couplable to the handle assembly 120.

The catheter assembly 130 includes a hub 132, a delivery sheath 136 and a traveler strap 134. The delivery sheath 136 defines a lumen (not shown in FIG. 2) through which the valve holding tube 125 can be inserted to deliver a prosthetic valve (not shown in FIG. 2) disposed within the valve holding tube 125 as described in more detail below. The hub 132 is disposed at a proximal end of the sheath 136 and defines an interior region through which the prosthetic valve is first introduced prior to insertion into the lumen of the sheath 136. In use, the hub 132 remains outside the heart and can provide access to the lumen of the sheath when it is inserted into the heart. The traveler strap 134 is coupled to the hub 132 and extends proximally from the hub 132. The traveler strap 134 is a thin or narrow elongate strap that can engage the handle assembly 120 as described in more detail below. The traveler strap 134 can be formed with, for example, various plastic and metal materials suitable for medical use.

The handle assembly includes a housing 122, an actuator 126 coupled to the housing 122, a tensioning unit 128 coupled to the housing 122, an elongate shaft 124 coupled to the housing 122 and extending distally from the housing 122, and a positioner 127 coupled to the housing 122. The actuator 126 can be in the form of a grip that is pivotally coupled to the housing 122 and a spring can bias the actuator 126 away from the housing 122. The actuator 126 is operatively coupled to the tensioning unit 128 such that when the actuator 126 is actuated by the user (e.g., gripped or squeezed such that a force is exerted against the spring), the actuator 126 causes the tensioning unit 128 to move a strap mount (not shown in FIG. 2) of the tensioning unit 128. The traveler strap 134 of the catheter assembly 130 can be coupled to the handle assembly 120 such that the traveler strap 134 engages the strap mount of the tensioning unit 128. Actuation of the tensioning unit 128 pulls the handle assembly 120 distally along the traveler strap 134. In some embodiments, the traveler strap 134 engages the strap mount with a friction fit. In some embodiments, the traveler strap 134 includes teeth along at least a portion of a length of the traveler strap 134 that engage the strap mount. Thus, the tensioning unit 128 can include a pawl coupled to the actuator such that the tensioning unit can function as a ratcheting mechanism to draw the handle assembly 120 along the traveler strap 134 with each actuation of the actuator 126.

The valve holding tube 125 can contain or hold a prosthetic mitral valve (not shown in FIG. 2) in a compressed configuration within an interior lumen of the valve holding tube 125. Although not shown in FIG. 2, in some embodiments, a valve loading device can be used to load the prosthetic valve into the valve holding tube 125 such that the prosthetic valve is compressed in a controlled manner to a desired compressed size and shape. Such a valve loading device is described in more detail below with reference to a specific embodiment. The valve holding tube 125 (with the prosthetic mitral valve therein) can be coupled to a distal end portion of the elongate shaft 124 of the handle assembly 120. For example, a portion of the distal end portion of the elongate shaft 124 of the handle assembly 120 can be received within an interior region of the valve holding tube 125. Prior to coupling the valve holding tube 125 to the elongate shaft 124, a tether (not shown) coupled to the prosthetic valve (within the valve holding tube 125) can be threaded through a lumen defined by the elongate shaft 124 and extend proximally out of the handle assembly 120.

The valve holding tube 125 can have various lengths to accommodate various different procedures to deliver the prosthetic heart valve to the heart. For example, in some embodiments, the valve holding tube 125 can have a length of between about 10 cm and 150 cm. In some embodiments, the valve holding tube 125 can have a length of about 12 cm to about 38 cm. In some embodiments, the valve holding tube 125 can have a length of about 50 cm to about 150 cm.

In some embodiments, the prosthetic heart valve (e.g., mitral valve) can be delivered apically, i.e. delivered through the apex of the left ventricle of the heart, using the delivery device 100 described herein. With such apical delivery, the delivery device 100 can access the heart and pericardial space by intercostal delivery. In this case, the valve holding tube 125 can have a length of, for example, 12-38 cm.

In another delivery approach, the delivery device 100 can deliver the prosthetic heart valve using either an antegrade or retrograde delivery approach without requiring the use of a rigid tube system that is commonly used in such procedures. In another embodiment, the delivery device 100 can access the heart via a trans-septal approach. In either case, where a long distance must be travelled, the valve holding tube 125 can have a length of, for example, 60-150 cm.

The positioner 127 can be mounted to a proximal end portion of the housing 122. A thumb screw or set screw can be used to secure the positioner to the housing 122. One or more tethers coupled to the prosthetic valve can extend through the handle assembly 120 and can also be inserted or threaded through the positioner 127. The positioner 127 can be used to fine tune the advancement or deployment of the mitral valve within the catheter assembly 130 and into the heart. A vise mechanism can be tightened around the tether to lock it in place. The positioner 127 can include a wheel or dial that can be rotated to adjust the tension on the tether to thereby adjust the speed at which the prosthetic valve can be deployed. When the dial is turned, a center tube extends proximally out of the positioner 127. The center tube includes deployment distance markings that can be used to inform the user how far the prosthetic valve has been advanced during the deployment procedure. The markings can be, for example, labeled with numbers or letters, or can be color coded. To deploy the prosthetic valve, the dial is rotated counterclockwise and to reposition the valve the dial is rotated clockwise. For example, after initially deploying the prosthetic valve, it may be desirable to repositioning the valve by retracting the valve into the sheath 136 of the catheter assembly 130. The tether attached to the prosthetic valve can be tightened, for example, using a slight rotation clockwise.

The positioner 127 can provide additional safety during a deployment procedure in that, with a compressed valve under great pressure, release from a catheter can launch the prosthetic valve, for example, a distance of many feet. However, with the positioner 127 provided herein and the ability to provide a slow calibrated deployment, the user can control the deployment to prevent the valve from inadvertently being projected from the valve holding tube 125 and sheath 136.

In use to deliver and deploy the prosthetic mitral valve within a heart, the sheath 136 of the catheter assembly 130 can be inserted through the epicardial surface of the patient's heart and extended through the left ventricle and to the left atrium of the heart such that the hub 132 is disposed on the outside of the heart near or in contact with the epicardial surface. In some embodiments, prior to introducing the sheath 136 into the heart, a guidewire is extended into the heart and to the left atrium. The sheath 136 can then be threaded over the guidewire to be inserted into the heart. In some embodiments, prior to inserting the sheath 136 into the heart, a dilator device (not shown in FIG. 2) can be inserted through the hub 132 and through the lumen of the sheath 136, such that a tapered distal end portion of the dilator device extends outside a distal end of the sheath 136. The tapered distal end of the dilator device can provide a lead-in for the sheath 136 and help open or enlarge the entry opening at the epicardial surface and through the mitral annulus. When the sheath 136 is placed at the desired position within the heart, the dilator device can be removed leaving the sheath 136 within the heart.

With the valve holding tube 125 coupled to the distal end portion of the elongate shaft 124 of the handle assembly 120, the traveler strap 134 of the catheter assembly 130 can be coupled to the strap mount of the tensioning unit 128 of the handle assembly 120. The valve holding tube 125 can then be inserted into the hub 132 of the catheter assembly 130 and o-rings (not shown in FIG. 1) on the valve holding tube 125 can maintain the position of the valve holding tube 125 within the hub 132. The actuator 126 of the handle assembly 120 can then be actuated by squeezing the actuator grip toward the housing 122 of the handle assembly 120 to cause the tensioning unit 128 to move or pull the handle assembly 120 distally along the traveler strap 134. As the handle assembly 120 moves distally, a distal end of the shaft 124 of the handle assembly 120 pushes the prosthetic valve out of the valve holding tube 125, into the lumen of the sheath 136 of the catheter assembly 130 and eventually out a distal end of the sheath 136 and into the left atrium of the heart. As the handle assembly 120 moves distally, the valve loading tube 125 remains stationary allowing the elongate shaft 124 of the handle assembly 120 to push the prosthetic valve out of the valve holding tube 125. After the prosthetic valve has been deployed, the positioner 127 can be used to help reposition the valve as needed.

FIGS. 3-9 illustrate a delivery device according to one implementation of the delivery device illustrated schematically in FIG. 2. A delivery device 200 includes a catheter assembly 230, a handle assembly 220 removably couplable to the catheter assembly 230 and a valve holding tube 225 removably couplable to the handle assembly 220. The delivery device 200 can be used to deliver and deploy a prosthetic heart valve within the heart, such as, for example, a prosthetic mitral valve (not shown) as described above for the previous embodiment.

The catheter assembly 230 includes a hub 232, a delivery sheath 236 and a traveler strap 234. The delivery sheath 236 defines a lumen 237 (see FIG. 7) through which a prosthetic valve can moved distally to deliver to a heart as described in more detail below. The hub 232 is disposed at a proximal end of the sheath 236 and defines an interior region 238 through which the valve holding tube 225 in which a prosthetic valve is disposed can be inserted. The traveler strap 234 is coupled to the hub 232 and extends proximally from the hub 232 as shown, for example, in FIGS. 3 and 7. The traveler strap 234 can be formed the same as or similar to the traveler strap 134 described above and can be coupled to the handle assembly 220 as described in more detail below.

The handle assembly 220 includes a housing 222, an actuator 226, a tensioning unit 228 (see FIGS. 5 and 6), an elongate shaft 224 and a positioner 227. The handle assembly 220 also includes a coupling block 229 that is used to couple the elongate shaft 224 to the housing 222. A hemostasis Y-adapter 239 disposed between the positioner 227 and the coupling block 229. The Y-adapter 239 can be used to connect, for example, a fluid line to the delivery device 200 to, for example, flush and purge the interior of the elongate shaft 224. The actuator 226 is in the form of a grip that is pivotally coupled to the housing 222 and a spring 242 biases the actuator 226 away from the housing 222. The actuator 226 is operatively coupled to the tensioning unit 228 via a pawl (not shown) such that when the actuator 226 is actuated, e.g., gripped or squeezed such that a force is exerted against the spring 242), the actuator 226 causes the pawl to move (e.g., rotate) a strap mount 244 (see FIGS. 5 and 6) of the tensioning unit 228. For example, when the actuator 226 is actuated, the strap mount 244 rotates clockwise. As described above, the traveler strap 234 of the catheter assembly 230 can be coupled to the handle assembly 220 such that the traveler strap 234 engages the strap mount 244 of the tensioning unit 228 as shown in FIG. 6. A retention member 231 is used to hold and maintain the traveler strap 234 coupled to the handle assembly 220. The retention member 231 can be rotated as shown in FIGS. 5 and 6 to provide access to the strap mount 244 and insert the traveler strap 234 to engage teeth 245 on the strap mount 244 (as shown in FIG. 6). In some embodiments, the traveler strap 234 engages the strap mount 244 with a friction fit. In some embodiments, the traveler strap 234 includes teeth (not shown) along at least a portion of a length of the traveler strap 234 that engage teeth 245 on the strap mount 244. Thus, the tensioning unit 228 can function as a ratcheting mechanism to pull the handle assembly 220 distally along traveler strap 234 with each actuation of the actuator 226.

The valve holding tube 225 (see, e.g., FIGS. 8 and 9) can contain or hold a prosthetic mitral valve (not shown) in a compressed configuration within an interior lumen 246 of the valve holding tube 225. As described in more detail below, a valve loading device (see, e.g., FIGS. 12-14) can be used to load the prosthetic valve into the valve holding tube 225 such that the prosthetic valve is compressed to a desired size and shape in a controlled manner. The valve holding tube 225 (with the prosthetic mitral valve therein) can be coupled to a distal end portion of the elongate shaft 224 of the handle assembly 220 as shown in FIG. 9. For example, a portion of the distal end portion of the elongate shaft 224 of the handle assembly 220 can be received through a proximal opening 248 of a cap member 249 and within the interior region 246 such that a distal end of the elongate shaft 224 is disposed proximal of the prosthetic valve within the valve holding tube 225. Prior to coupling the valve holding tube 225 to the elongate shaft 224, a tether (not shown) coupled to the prosthetic valve (within the valve holding tube 225) can be threaded through a lumen defined by the elongate shaft 224, through the positioner 227 and extend proximally out of the handle assembly 220. The valve holding tube 225 also includes markings 257 and 259 that can be used to align to corresponding marks (not shown) on the distal end portion of the elongate shaft 224 of the handle assembly 220. The valve loading tube 225 also includes o-rings 253 on a distal end portion 241 (see FIG. 8) of the valve holding tube 225 that can be used to hold the valve holding tube 225 within the interior region 238 of the hub 232 of the catheter assembly 230.

As described above for the previous embodiment, the valve holding tube 225 can have various lengths to accommodate various different procedures to deliver the prosthetic heart valve to the heart. For example, in some embodiments, the valve holding tube 225 can have a length of between about 10 cm and 150 cm. In some embodiments, the valve holding tube 225 can have a length of about 12 cm to about 38 cm. In some embodiments, the valve holding tube 225 can have a length of about 50 cm to about 150 cm.

The positioner 227 is mounted to a proximal end portion of the housing 222. A set screw(s) 247 can be used to secure the positioner 227 to the housing 222. The positioner 227 can be used to fine tune the advancement or deployment of the mitral valve within the catheter assembly 230 and into the heart. As described above, one or more tethers coupled to the prosthetic valve can be passed or threaded through a lumen of the positioner 227 and extend out an opening 233 (see FIG. 4). A vise (not shown) within the positioner 227 can be tightened around the tether to lock it in place. The positioner 227 includes a wheel or dial 250 that when turned extends a center tube 251 proximally out of the positioner 227. The center tube 251 can include deployment distance markings (not shown) that can be used to inform the user how far the prosthetic valve has been advanced during deployment. The markings can be, for example, labeled with numbers or letters, or can be color coded. To deploy the prosthetic valve, the dial is rotated counterclockwise and to reposition the valve the dial is rotated clockwise. The tether can be tightened using a slight rotation clockwise.

To deliver and deploy the prosthetic mitral valve within a heart, the sheath 236 of the catheter assembly 230 is inserted through the epicardial surface of heart and extended through the left ventricle and to the left atrium of the heart such that the hub 232 is disposed on the outside of the heart near or in contact with the epicardial surface. In some embodiments, prior to introducing the sheath 236 into the heart, a guidewire is extended into the heart and to the left atrium. The sheath 236 can then be threaded over the guidewire. In some embodiments, prior to inserting the sheath 236 into the heart, a dilator device 254 (see FIGS. 10 and 11) can be inserted through the hub 232 and through the lumen of the sheath 236, such that a tapered distal end portion 255 of the dilator device 254 extends outside a distal end of the sheath 236. The tapered distal end portion 255 of the dilator device 254 can provide a lead-in for the sheath 236 and help open or enlarge the entry opening at the epicardial surface and through the mitral annulus. When the sheath 236 is placed at the desired position within the heart, the dilator device 254 can be removed leaving the sheath 236 within the heart.

With the valve holding tube 225 coupled to the distal end portion of the elongate shaft 224 of the handle assembly 220, the traveler strap 234 of the catheter assembly 230 can be coupled to the strap mount 244 of the tensioning unit 228 of the handle assembly 220 (as shown in FIGS. 3 and 6). The distal end portion 241 of the valve holding tube 225 can then be inserted into the interior region 238 of the hub 232 and the o-rings 253 can secure the valve holding tube 225 in a stationary or fixed position within the lumen 238 of the hub 232 (as shown in FIG. 3). The actuator 226 of the handle assembly 220 can then be actuated by squeezing the actuator grip toward the housing 222 of the handle assembly 220 to cause the tensioning unit 228 to pull or move the handle assembly 220 distally. As the handle assembly 220 moves distally, a distal end of the elongate shaft 224 of the handle assembly 220 pushes the prosthetic mitral valve out of the valve holding tube 225, into the lumen 237 of the sheath 236 of the catheter assembly 230 and eventually out a distal end of the sheath 236 and into the left atrium of the heart. As the prosthetic mitral valve is released with the heart, and is no longer contained within the valve holding tube 225 or the sheath 236, the prosthetic mitral valve can assume an expanded configuration. Each actuation of the actuator 226 incrementally moves the handle assembly 220, providing a controlled incremental release of the prosthetic mitral valve within the heart. As described above, the positioner 227 can be used to control the rate of deployment of the prosthetic valve and/or can be used to reposition the valve as needed.

FIGS. 12-14 illustrate a valve loading device 260 that can be used to compress the prosthetic valve to a desired size and shape prior to loading the valve into the valve holding tube 225. The valve loading device 260 includes an inner funnel 262, a removable outer funnel 263 and a removable centering tube 264. The outer funnel 263 and centering tube 264 can be removably coupled to the inner funnel 262 via a bracket assembly 267. The bracket assembly 267 can be coupled and uncoupled from the outer funnel 262 using bolts or screws 268.

The process of loading the prosthetic valve into the valve loading device 260 (also referred to as “loading device”) should be performed with the valve and loading device 260 submerged in a saline/water bath with care being taken to remove all trapped air bubbles within the loading device 260. The outer funnel 263 and centering tube 264 are removed from the inner funnel 262. The prosthetic heart valve can be placed within a larger diameter area of an interior region 265 defined by the inner funnel 262 (shown in FIG. 13). The tether of the valve is threaded through the inner funnel 262. In some embodiments, with an asymmetric prosthetic mitral valve, the valve is loaded into the loading device 260 so that the A2 section of the valve (see PCT application '58826) is loaded upwards. This can ensure that the A2 segment of the valve is compressed in the same way it is delivered to the A2 region of the anterior native leaflet to reduce or prevent LVOT obstruction.

The outer funnel 263 and centering tube 264 can then be coupled to the inner funnel 262 and the centering tube 264 to hold the prosthetic valve in position within the interior region 265. For example, the centering tube 264 can be inserted through a center of the valve and through a center of the outer funnel 263 and inner funnel 262. The valve can be checked for air, shaken, tapped to remove trapped air, etc. while within the loading device 260. If any bubbles are seen, they can be removed with a syringe, especially out of any top pockets of the valve.

Next, the handle assembly 220 can be used to draw or move the prosthetic valve from the valve loading device 260 to the valve holding tube 225. For example, the valve loading tube 225 can be coupled to an exit end of the valve loading device 260 as shown in FIG. 14. A load assist device 269 can be coupled between the handle assembly 220 and the valve holding tube 225, as shown in FIGS. 15 and 16. The load assist device 269 secures the valve holding tube 225 and valve loading device 260 in a fixed relation to the handle assembly 220. The tether 275 (as shown in FIGS. 15 and 16) of the prosthetic valve (disposed within the loading device 260 in FIG. 15 and within the valve holding tube 225 in FIG. 16) can be threaded through the lumen of the valve holding tube 225 and coupled to a first bracket 271 of the load assist device 269. For example, a piercing pin can be used to secure the tether 275 to the first bracket 271. The load assist device 269 includes a load assist strap 277 also coupled to the first bracket 271. A second bracket 273 can be used to hold the valve holding tube 225. For example, the second bracket 273 can define a groove or cut-out that can receive the valve holding tube 225.

With the load assist strap 277 engaged with the tensioning unit 228 of the handle assembly 220, the handle assembly 220 can be actuated in the same manner as described above (e.g., by gripping or squeezing the actuator 226), which will draw the load assist strap 277 toward the handle assembly 220 pulling the first bracket 271 with it. Thus, the first bracket 271 can be moved from a first position (closer to the second bracket 273), as shown in FIG. 15 to a second position (closer to the handle assembly 220) as shown in FIG. 16. Because the tether 275 is coupled to the first bracket 271, the movement of the first bracket 271 pulls the tether 275, and thus, pulls the prosthetic valve toward the handle assembly 220 and out of the valve loading device 260 and into the valve holding tube 225. With the valve disposed within the valve holding tube 225, the load assist device 269 can be decoupled from the handle and from the valve holding tube 225.

FIGS. 17A and 17B illustrate a portion of an alternative embodiment of a handle assembly that can be used to move the prosthetic valve from the loading device 260 to the valve holding tube 225. A handle assembly 320 can be constructed the same as or similar to the handle assembly 220. Only those portions that vary are discussed here. The handle assembly 320 includes a modified coupling block 329 and tensioning unit 328. The tensioning unit 328 includes a strap mount 344 similar to the strap mount 244 and can be actuated in a similar manner as described for handle assembly 220. The strap mount 344 includes teeth 345 that can engage a load assist strap 377 of a load assist device such as load assist device 269 described above. In this embodiment, the coupling block 329 also includes teeth 379 that can engage the load assist strap 377 (shown in FIG. 17B) of the load assist device. The teeth 379 provide for movement of a load assist device in only one direction. As with the previous embodiment, a retention member 331 can be rotated to gain access to load or insert the load assist strap 377.

FIG. 18 is a flowchart illustrating a method of deploying a prosthetic mitral valve into a heart, according to an embodiment. At 470, a prosthetic mitral valve is loaded into a valve loading device and moved from a biased expanded configuration to a compressed configuration within the valve loading device. At 472, the prosthetic mitral valve is transferred to a valve holding tube while maintaining the compressed configuration. At 474, the valve holding tube with the prosthetic mitral disposed therein in a compressed configuration is coupled to a distal end portion of a handle assembly of a valve delivery device. In some embodiments, prior to coupling the valve holding tube to the distal end of the handle assembly, a tether coupled to the prosthetic mitral valve is threaded through a lumen of the handle assembly and through a lumen of a positioning device of the handle assembly. The positioning device can be used to hold the tether and control movement of the prosthetic mitral valve during deployment into the heart. For example, a dial on the positioning device can be moved or rotated to adjust a tension on the tether extending through the positioning device. At 476, a sheath of a catheter assembly is inserted into a heart and extended to the left atrium of the heart. At 478, after inserting the sheath of the catheter assembly into the heart, the valve holding tube (while coupled to the distal end of the handle assembly) is inserted partially into the hub of the catheter assembly which extends outside of the heart. At 480, the handle assembly is actuated such that the handle assembly is moved distally and a distal end of the handle assembly moves the prosthetic mitral valve distally out of the valve holding tube and out a distal end of the sheath and into the left atrium of the heart. The prosthetic mitral valve is moved to a biased expanded configuration within the heart when uncompressed within the holding tube and sheath. In some embodiments, the handle assembly includes an actuator coupled to a tensioning unit, the catheter assembly includes a traveler strap configured to be coupled to the tensioning unit, and the actuation of the handle assembly includes actuating the actuator such that the tensioning unit pulls the handle assembly distally along the traveler strap.

FIG. 19 is a schematic illustration of a kit according to an embodiment. In some embodiments, a surgical kit 580 can include a delivery device 500 which can be, for example, a delivery device as described herein (e.g., delivery device 100, 200) and a valve loading device 560. A kit can optionally include one or more of a transcatheter prosthetic valve 582 (e.g., a prosthetic mitral valve) and/or an epicardial pad 584 to secure the transcatheter valve 582 in position within the heart and/or a dilator device 554 as described herein and/or a guidewire (not shown in FIG. 19). A kit can also include a sterile package in which the components of the kit can be sealed for transport.

While various embodiments have been described above, it should be understood that they have been presented by way of example only, and not limitation. Where methods described above indicate certain events occurring in certain order, the ordering of certain events may be modified. Additionally, certain of the events may be performed concurrently in a parallel process when possible, as well as performed sequentially as described above

Where schematics and/or embodiments described above indicate certain components arranged in certain orientations or positions, the arrangement of components may be modified. While the embodiments have been particularly shown and described, it will be understood that various changes in form and details may be made. Any portion of the apparatus and/or methods described herein may be combined in any combination, except mutually exclusive combinations. The embodiments described herein can include various combinations and/or sub-combinations of the functions, components, and/or features of the different embodiments described. 

The invention claimed is:
 1. An apparatus, comprising: a catheter assembly including a sheath; a handle assembly operably coupled to the sheath, the handle assembly including a shaft and an actuator; a positioning device; and a prosthetic heart valve configured to be received within the sheath in a collapsed configuration, the prosthetic heart valve including a tether configured to be received within the positioning device; wherein the actuator, when actuated, is configured to advance the prosthetic heart valve distally relative to the sheath, and the positioning device, when the tether is secured within the positioning device, is configured to restrict movement of the prosthetic heart valve relative to positioning device.
 2. The apparatus of claim 1, wherein the positioning device is configured to be fixedly mounted to the handle assembly.
 3. The apparatus of claim 2, wherein the positioning device includes a vise that can be tightened to lock the tether to the positioning device.
 4. The apparatus of claim 1, wherein the positioning device includes a dial rotatable in a first direction to draw the tether proximally relative to the sheath.
 5. The apparatus of claim 4, wherein the dial is rotatable in a second direction opposite the first direction to allow the tether to advance distally relative to the sheath.
 6. The apparatus of claim 5, wherein the positioning device includes a tube configured to be secured to the tether, and rotation of the dial in the first direction moves the tube proximally, while rotation of the dial in the second direction advances the tube distally.
 7. The apparatus of claim 6, wherein the tube includes deployment distance markings that correspond to a distance which the prosthetic heart valve has been advanced during a deployment procedure.
 8. The apparatus of claim 1, wherein the actuator, when actuated, is configured to advance the shaft distally within the sheath.
 9. The apparatus of claim 8, wherein when the prosthetic heart valve is received within the sheath in the collapsed configuration, a distal end of the shaft is adapted to abut a proximal end of the prosthetic heart valve.
 10. The apparatus of claim 9, wherein the tether is coupled to the proximal end of the prosthetic heart valve and is configured to extend through a lumen in the shaft to a lumen in the positioning device.
 11. A method of deploying a prosthetic heart valve, the method comprising: inserting a sheath of a catheter into a heart of a patient; actuating an actuator of a handle assembly to drive a shaft of the handle assembly distally through the sheath; wherein, driving the shaft of the handle assembly distally through the sheath drives a prosthetic heart valve distally through the sheath, the prosthetic heart valve received within the sheath in a collapsed configuration; wherein, while the prosthetic heart valve is driven distally through the sheath, a tether coupled to the prosthetic heart valve is received within a positioning device so as to restrict movement of the prosthetic heart valve relative to positioning device.
 12. The method of claim 11, further comprising tightening a vise of the positioning device to lock the tether to the positioning device prior to driving the prosthetic heart valve distally through the sheath.
 13. The method of claim 11, further comprising rotating a dial of the positioning device in a first direction to begin deploying the prosthetic heart valve out of the distal end of the sheath into the heart of the patient.
 14. The method of claim 13, further comprising rotating the dial of the positioning device in a second direction opposite the first direction to begin drawing the prosthetic heart valve back into the sheath.
 15. The method of claim 14, wherein rotation of the dial in the first direction moves a tube of the positioning device distally, the tether being secured to the tube.
 16. The method of claim 15, wherein the tube includes deployment distance markings that correspond to a distance which the prosthetic heart valve has been advanced during a deployment procedure.
 17. The method of claim 11, wherein the tether is coupled to the proximal end of the prosthetic heart valve and extends through a lumen in the shaft to a lumen in the positioning device while the prosthetic heart valve is driven distally through the sheath.
 18. The method of claim 11, wherein actuating the actuator pulls a strap proximally relative to the handle assembly, a distal portion of the strap being operably coupled to the sheath.
 19. The method of claim 18, wherein pulling the strap proximally relative to the handle assembly advances the shaft distally relative to the sheath.
 20. The method of claim 11, further comprising: inserting the prosthetic heart valve into an interior region of a valve loading device while in a biased expanded configuration; moving the prosthetic heart valve from the biased expanded configuration to the collapsed configuration while disposed within the valve loading device; transferring the prosthetic heart valve while in the compressed configuration from the valve loading device to a valve holding tube; and coupling the valve holding tube with the prosthetic heart valve disposed therein in the compressed configuration to a distal end of the shaft prior to driving the prosthetic heart valve distally through the sheath. 